Arnold P. Robin

Peritoneal lavage in penetrating thoraco-abdominal trauma.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.

The use of absorbable mesh in splenic trauma

Previous reports from this hospital documented a splenic preservation rate of 50% (18/36) in adults after blunt and penetrating trauma. Recently (January through December 1984), use of an absorbable mesh helped to attain a 67% (22/33) salvage rate. The mesh is applied in such a fashion that it acts by tamponade. It proved useful in patients with bleeding from a large surface area or from deep parenchymal injuries, even those extending into the hilum. No deaths occurred in the splenic salvage patients. There was no difference in postoperative complications among the splenectomy, conventional splenorraphy, or mesh wrap splenorraphy groups. However, workup of persistent postoperative fevers in two splenic wrap patients revealed perisplenic fluid collections on CT scan. Aspiration yielded sterile fluid. Possible cause and effect relationship is being studied in the dog lab. We conclude that splenic wrapping is both a safe and efficacious method of splenic preservation.

Intravenous Fat Emulsion Acutely Suppresses Neutrophil Chemiluminescence

The immediate effect of intravenous fat emulsion on neutrophil oxidant release was studied. Opsonized nonencapsulated S. aureus was used to stimulate neutrophil activity. Luminol enhanced chemiluminescence was followed over 15 min and recorded as peak output (P; mV), integral under the curve (I; V-sec) and rate of increase (R; mV/sec). Eighteen chronically ill patients receiving glucose based total parenteral nutrition were studied before and after a 4- to 6-hr test infusion of 500 ml of 10% fat emulsion. P decreased from 719 +/- 46 to 461 +/- 42 mV (p less than 0.001), I decreased from 169 +/- 17 to 111 +/- 12 V-sec (p less than 0.001) and R decreased from 6.9 +/- 1.0 to 4.0 +/- 0.6 mV/sec (p less than 0.001). Preincubation of normal whole blood with fat emulsion in vitro did not adversely affect chemiluminescence (11 studies), nor did incubation of normal neutrophils with patient postinfusion plasma (10 studies). We conclude that fat emulsion infusion acutely suppresses neutrophil chemiluminescence. The suppression is not a direct effect of the fat emulsion per se and is not due to inhibitory substances in the plasma following infusion.

The effect of urban trauma system hospital bypass on prehospital transport times and level 1 trauma patient survival

We studied the influence of hospital bypass on prehospital times and Level 1 trauma patient survival. During the nine-month study period, 251 Level 1 trauma patients were transported to the Cook County Hospital trauma unit by Chicago Fire Department (CFD) paramedics. The prehospital times and survival rates in the 203 (81%) patients who arrived with vital signs were analyzed. In this group, 64 (32%) had a hospital Trauma Score (TS) of 12 or less, 74 (39%) had at least one Abbreviated Injury Score (AIS) of 4 or more, and 58 (30%) had an Injury Severity Score (ISS) of more than 20. There were 66 (32%) directly transported patients and 137 (68%) patients who required hospital bypass. The time from CFD contact (by 911) to trauma center arrival (total run time) was on the average three minutes longer in the bypass group than in the direct group (36 +/- 11 vs 33 +/- 10 minutes, P less than .05). The travel time from the scene to the hospital (transport time) also was three minutes longer in the bypass group (7 +/- 3 vs 4 +/- 2 minutes, P less than .005). The need for bypass did not significantly influence survival. Survival was 86% in the bypass group and 85% in the direct group. The elapsed time between the injury and CFD contact (delay time) averaged 27 +/- 26 minutes and contributed 43% to the 63-minute mean overall time from the injury event to arrival at the trauma center. Total run time in directly transported patients accounted for 52% of the mean overall prehospital time.(ABSTRACT TRUNCATED AT 250 WORDS)

Absorbable mesh splenorrhaphy for severe splenic injuries : functional studies in an animal model and an additional patient series

Polyglycolic acid mesh has been introduced as a method of controlling hemorrhage in severely damaged spleens. This study examines the effect of splenic wrapping on the immune function of the spleen, and also on its ability to control splenic bleeding in trauma patients. Thirty purebred beagle dogs were divided into three groups and subjected to sham operation (Group 1), splenectomy (Group 2), and splenic wrap (Group 3). Immunologic studies showed no difference between the wrapped group (Group 3) and those with their spleens intact (Group 1) in the induction of specific antibody-producing lymphocytes in splenic tissue after the injection of attenuated Pneumococci. All splenic injuries treated at Cook County Hospital between January 1985 and May 1988 were retrospectively analyzed. Of 60 patients with splenic injuries, 14 underwent mesh splenorrhaphy without mortality or serious complications. This study demonstrates that the immune function of spleen is preserved following mesh splenorrhapy, and that this technique can be used in a clinical setting with safe and efficacious results.

Fibronectin Depletion and Microaggregate Clearance following Trauma

Ninety-seven traumatized patients had blood samples taken immediately upon admission before any resuscitation. Microaggregate (MA) formation was measured by the screen filtration pressure (SFP) technique. Plasma fibronectin levels (Fn) were measured by immunoturbimetric assay. An Injury Severity Score (ISS) was calculated for each patient. The results show a highly significant correlation between severity of trauma, amount of MA formation, and amount of Fn depletion. We conclude that the highly significant correlation between MA formation and Fn depletion following trauma suggests a role for the reticuloendothelial system (RES) in the clearance of MA that form following trauma. Further, enhancement of RES clearance of MA may be possible by purified Fn or cryoprecipitate administration early in the treatment of trauma patients, thereby preventing the adverse sequelae of end organ MA deposition.

Salmonella typhi splenic abscess in an intravenous drug abuser following splenorrhaphy: case report.

A recent case of posttraumatic splenic abscess in an HIV-positive intravenous drug abuser following a splenic salvage procedure is reported. With the recent trend toward splenic preservation and the ever-increasing population of HIV-positive, immune-compromised patients, the complication of splenic abscess may become more common.

Congenital Diaphragmatic Hernia with Liver Injury Presenting as Bilious Hydrothorax

Congenital diaphragmatic hernia is a rare occurrence in the adult population. We present herein a patient with blunt abdominal trauma who presented with a bilious right pleural effusion. Bile from a m